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Name: G Sai Manogna
Roll no: 33
I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a diagnosis and treatment plan.
Following is the view of my case :
CASE PRESENTATION
A 55 yr old male who is barber by occupation resident of suryapet has come to the opd with the chief complaint of-
Pain in the epigastric region since 1 day
HOPI-
Patient was apparently asymptomatic 1 day ago then he developed pain in the epigastric region after consuming alcohol previous night and pain has started in the morning after intake of food in the morning
It was sudden in onset, increasing in intensity and is of squeezing type. Pain is persistent throughout the day. It later radiated to whole of the abdomen
No h/o fever, nausea and vomitings
Past history-
Previously 15 yrs back, patient had pain abdomen
Then diagnosed with intestinal perforation and had undergone a surgery and was discharged 1 week after the surgery
Patient is not a known case of hypertension, diabetes, asthma, tuberculosis
No history of gall stones?
No history of blood transfusions?
Personal history-
Diet is mixed?
Appetite is decreased
Sleep is inadequate
B/B movements were regular
Addictions-
Alcoholic since 25 yrs- Takes 90 to 180 ml whisky daily
Allergic history-
No history of known allergies
Family history-
No similar complaints
No comorbidities
General examination-
Done after obtaining a consent, in a well lit room, in the presence of an attendant with adequate exposure
The patient is conscious, coherent, cooperative,well oriented to time, place and person
Well nourishee and moderately built
Pallor ab
Icterus ab
Cyanosis ab
Clubbing ab
Lymphadenopathy ab
Edema ab
Vitals-
Temp- afebrile
Pulse rate- 78bpm
Respiratory rate- 18cpm
Blood pressure- 140/100 mmHg
SPO2- 98%
Systemic examination-
CVS- S1 and S2 heard
RS- Bilateral air entry present, normal vesicular breath sounds are heard
CNS- No focal deficit
Abdomen-
Inspection-
On inspection abdomen is distended and umbilicus is inverted.
Presence of previous surgical scar
No visible peristalsis, pulsations, engorged veins and no hernial sites
Negative cullen's sign, grey turner's sign, fox's sign
Palpation-
Inspectory findings confirmed. There is tenderness in the epigastric region. No guarding and rigidity
Percussion-
Tympanic sounds are heard
Auscultation- No bowel sounds are heard. No bruits
Investigations-
Hemogram-
Hb- 13.8
TLC- 12700
Platelets- 2.1 L
RFT-
Urea- 20
S.Creatinine- 0.9
Serum electrolytes-
Na+ -139
K+ -3.2
Cl- -103
USG-
ECG
Serum amylase-579.4
Serum lipase-
Provisional diagnosis-
Acute pancreatitis due to alcohol dependence
Treatment-
IVF NS and RL
Inj. Pan
Inj. Zofer
Inj. Tramadol
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